Carroll County Promise 2020: Community Health Improvement Plan 2016-2020 - Carroll County Coalition for ...
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Carroll County Promise 2020: Community Health Improvement Plan 2016-2020
Carroll County Promise 2020
Table of Contents
Acknowledgements ................................................................................................................ 3-4
Executive Summary ................................................................................................................ 5-6
Introduction:
• Overview ................................................................................................................................ 7
• Community Profile .................................................................................................................. 8
• Vision and Mission of Carroll County Coalition for Public Health ............................................... 11
• Carroll County Promise 2020 Community Health Improvement Plan Development .................... 11
o Overview
o Planning Steps
o Needs Assessments and Data
Carroll County Promise 2020 Community Health Improvement Plan Priority Areas:
• Early Childhood and Parenting Support ................................................................................. 13
• Access to Comprehensive Behavioral Health Services ............................................................. 17
• Substance Misuse and Addiction .......................................................................................... 22
• Chronic Disease ................................................................................................................... 27
• Aging with Connection and Purpose ....................................................................................... 31
• Emergency Preparedness Across the Life Span ...................................................................... 35
Cover Photo of Mt.Chocorua overlooking Chocorua Lake by Woodland Images, 2016.
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Carroll County Promise 2020
Acknowledgements
The following individuals served as the core Public Health Advisory Council Executive Committee
in 2015 and were actively involved in the development of the initial draft of Carroll County Promise
2020, Carroll County Coalition for Public Health’s Community Health Improvement Plan:
Beth Hertzfeld – Principal of Ossipee Central School. Beth has decades of experience in Ossipee
and particular interest in access to mental health and substance abuse services for young families.
Doug Wyman – Chief of Police in Sandwich. Doug has been an outspoken advocate for improving
the way our county responds to and supports residents with mental health and substance use
issues.
Howard Chandler – Administrator of Mountain View Nursing Home. Howard runs this Carroll
County resource and is eager to provide more services for seniors across the whole county.
Jane MacKay – Area Director of Northern Human Services. Jane has weathered the storm of
repeated slashes to behavioral health funding and has identified some promising models for rural
regions.
Jeanne Ryer – Director of NH Citizens Health Initiative. Jeanne’s organization has shone a
spotlight on the tremendous impact that demographic changes will have on the health status of
Carroll County.
Jo Anne Rainville – Executive Director of Tamworth Community Nurses Association. Jo Anne runs a
town and community funded program that provides office and home-based preventive services to
ALL ages.
Kathy Barnard – Planning Board Chair for Town of Wolfeboro. Along with multiple volunteer and
government posts, Kathy works with the Eastern Lakes Region Housing Coalition and serves on the
Board of Trustees of Huggins Hospital.
Mike Connelly – Past CEO of Huggins Hospital. Mike, like other leaders of small rural hospitals, is
responding to tremendous change in the financing and delivery of health services in rural areas.
Mike Coughlin – Executive Director of Tri-County Community Action Program. As the new Director,
of Tri-CAP, Mike is leading a strategic planning process to revitalize and realign its core services.
Patricia McMurry – Executive Director of White Mountain Community Health Center. Patricia is
actively seeking to increase access to substance abuse services and other primary and preventive
care.
Peter Whelley – School Psychologist for Moultonborough Public Schools. Peter co-leads a local
coalition that helped develop a model that provides town-voter-funded support for local mental
health services.
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Carroll County Promise 2020
Sandy Ruka – Executive Director of VNA Hospice of Northern Carroll County & Vicinity. Sandy
chairs the White Mountain Community Health Council, a coalition of providers in the valley.
Sue Ruka – Director of Population Health at Memorial Hospital. Sue has taken on this new role at
Memorial with a keen interest in county-wide efforts to address obesity and health needs of the
aging.
Susan Ticehurst – NH State Representative for Albany, Madison, Tamworth. As a representative,
Susan is part of both the State Legislature and the County Delegation that votes on county funding
decisions.
Theresa Kennett – Executive Director of Mount Washington Housing Coalition. Theresa also chairs
the Mount Washington Valley Regional Collaborative focused on housing and workforce issues and
more.
The following individuals, as part of their new roles as members of C3PH’s Public Health Advisory
Council Executive Committee, provided their advice and input into the final draft of the plan in
2016:
Kristy LeTendre - Director of Clinical Services, Tri-County Community Action Program
Victoria Laracy - Executive Director of Mt. Washington Valley Housing Coalition
Schelley Rondeau - Director, Central New Hampshire Visiting Nurse Association
Pamela Clay-Storm - Nurse, Kennett High School
John Whittier - Director, Ossipee Concerned Citizens
Ed Butler - NH House Representative District 7, Carroll County Delegation
Jason Henry - Superintendent, Carroll County House of Corrections
Monika O’Clair - Senior Director of Communication and Community Relations, Huggins Hospital
Marian Gill - Director, Service Link of Carroll and Belknap Counties
Chuck Henderson - Special Assistant for Policy and Projects, Office of United States Senator Jeanne Shaheen
And many thanks to these subject matter experts who are members of our working groups that are
already addressing various health priority areas: Marianne Jackson and Danielle Koffenberger.
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Carroll County Promise 2020
Executive Summary
The staff of Carroll County Coalition for Public Health (C3PH) and their Public Health Advisory
Council (PHAC), which consists of the general membership known as the Carroll County Roundtable
and the PHAC Executive Committee, are proud to present the Carroll County Community Health
Improvement Plan (CHIP) entitled “Carroll County Promise 2020.” Carroll County Promise 2020
tackles public health challenges that no one organization or community can address in isolation.
We are interdependent. Like the opioid crisis that has captured recent headlines, the 6 public
health priorities we identify cut across town lines, across generations. We commit to working
together as a county to forge county-wide solutions.
The Carroll County Public Health Advisory Council (PHAC) is a group of local leaders representing
medical, mental health, education, social service, government, and business communities who
convened in April 2015 to craft a shared vision of where we want to be together by 2020. In 2016,
after a change in C3PH staffing, new membership on the PHAC Leadership Team and the release of
the Huggins Hospital and Memorial Hospital Community Health Needs Assessments, this final plan
was adopted.
To assess where we are now, C3PH’s PHAC reviewed key local population health data including the
Huggins Hospital and Memorial Hospital Community Health Needs Assessments (both 2013 and
2016) and the Mount Washington Valley Housing Matters Report (2012). Data from the NH Citizens
Health Initiative was reviewed to anticipate key demographic trends likely to impact population
health in Carroll County in the coming decades. We compared local health factors and outcomes
with other counties in the state and nation using data from the Annie E. Casey Foundation. Finally,
we investigated within-county data at the census-tract level using the NH Social Vulnerability Index
(see http://nhdphs.maps.arcgis.com for a visual tour of disparities in Carroll County) to identify
demographic, social, and economic disparities among our diverse rural towns:
• Together, we are the fastest aging population in New Hampshire. We have the highest
percentage of population over age 65 (24.5%) of any county in the state and the
correspondingly highest projected levels of primary care demand.
• Together, we share the housing and workforce challenges of a seasonal tourism
economy. Wages in retail and service industries have not nearly kept up with housing costs
leading many to struggle or migrate to secure affordable housing and employers report
difficulty attracting and retaining workers.
• Yet, our 17 towns experience wide disparities in factors impacting the health of residents.
Levels of poverty, disability, and education, as well as percentages of children and the
elderly vary widely across town lines. Generally, residents across the middle two-thirds
of the county have higher levels of socio-economic vulnerability and are also most distant
from the medical, educational, and social services associated with the hubs of Wolfeboro
and North Conway.
• And, Carroll County residents at key generational turning points face heightened risks.
Poverty rates in Carroll County, for example, are highest among our youngest children,
young adults who are just entering parenthood and the workforce, and the elderly.
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Carroll County Promise 2020
Setting Priorities for Carroll County 2020: Drawing on these key social determinants of health in
Carroll County, we selected priorities with an eye to demographic trends, geographic disparities,
and the risks facing residents at generational turning points. We focused intentionally on areas
that participants in the Huggins Hospital and Memorial Hospital Community Needs Assessments
identified as public health priorities in need of more resources and collaboration, as well as those
priorities where strategies and funding resources were already in place. Finally, in recognition
of our shared economic challenges, we selected priorities that complement efforts to prepare,
attract, and retain the workforce and employers of the future. Six priorities were selected that met
these criteria:
• Early Childhood and Early Parenting Support
• Access to Comprehensive Behavioral Health Services
• Substance Misuse and Addiction
• Chronic Disease
• Aging with Connection and Purpose
• Emergency Preparedness Across the Lifespan
Workgroups associated with each priority will be identifying and establishing benchmarks that
are readily measurable on an annual basis and for which baseline data exists or can efficiently
be gathered. Benchmarks will be chosen to closely align with key objectives outlined in the New
Hampshire State Health Improvement Plan.1 To address each goal, we will highlight a small group
of promising evidence-informed approaches that are already underway or can be embarked upon
by county-wide workgroups to make a difference. The benchmarks will be used to measure our
progress and hold ourselves accountable to our promise.
Changing the Carroll County Narrative – From Pessimism to Promise:
In years when both county and state budgets are beset with challenges that hamper efforts to
expand public health resources, we refuse to be held back by pessimism. We are determined to
focus on promising solutions that bring out the best of local ingenuity, collaboration, and mutual
aid that are at the heart of Carroll County.
1 NH State Health Improvement Plan: http://www.dhhs.nh.gov/dphs/documents/nhship2013-2020.pdf
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Carroll County Promise 2020
Introduction
Overview
The Carroll County Public Health Network is one of the 13 regional public health networks in
New Hampshire.2 Each Regional Public Health Network (RPHN) includes a fiscal agent, a PHAC
lead, Public Health Emergency Preparedness and Substance Misuse Prevention coordinators,
and a Continuum of Care facilitator. Carroll County Coalition for Public Health was established
in 2009 as a 501(c)3 organization to serve as the host agency for the Carroll County Public
Health Network. The new organization consisted of a governing body of a volunteer Board of
Directors which was representative of Carroll County communities and included heathcare, town
representatives, emergency management personnel and members of the Regional Coordination
Committee. In 2016 NHDHHS reassigned the contract to Granite United Way to serve as the host
agency for Carroll County Coalition for Public Health, allowing C3PH to terminate their 501(c)3
status and become an intiative of Granite United Way. The initial Carroll County Public Health
Advisory Council (PHAC) was a group of local leaders representing medical, mental health,
education, social service, government, and business communities who convened in April 2015
to develop Carroll County Promise 2020. After Granite United Way became the host agency, it
was determined that the Carroll County Roundtable could serve as the general membership of
the Public Health Advisory Council. A new Public Health Advisory Council Executive Committee
was convened, reflecting changes in staffing of organizations that had been involved in the
initial CHIP development (see list of planning participants under acknowledgements, pg. 1)
Carroll County Promise 2020 Community Health Improvement Plan (CHIP) outlines 6 priority areas
of focus, representing the most significant health issues facing our region. Working groups are in
various stages of development to address these priorities. The proposed strategic approaches
are based on significant evidence and have been shown to significantly impact the identified
goals and objectives. Carroll County Promise 2020 CHIP aligns with existing assessments and
plans, including the Huggins and Memorial Hospital 2016 Community Health Needs Assessments,
the 2013-2020 New Hampshire State Health Improvement Plan (SHIP) and the 2016 Youth Risk
Behavior Survey. Carroll County Promise 2020 CHIP serves as a guide to be used for collective
action by key stakeholders from a variety of community sectors, including business, education,
health, safety, government and community/family supports. These sectors witness the impact of
the public health concerns identified in this plan,and they can also play a valuable role in leading
efforts to address the factors that influence health outcomes in the region. The identified priority
areas are too complex for one organization or sector to solve on its own. Carroll County Promise
2020 CHIP provides a framework for multiple entities to systematically address shared priorities to
achieve significant improvements in the health of our communities.
2 New Hampshire Regional Public Health Networks: http://nhphn.org/who-we-are/
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Carroll County Promise 2020
Community Profile
The Carroll County Public Health Region is composed of
19 communities spread across a geographic area of 934
square miles with a total population of approximately
47,000 people. Carroll is the only county in New
Hampshire that does not contain a city. Compounding
the lack of a central urban core are the multiple and
overlapping divisions in the county by school district,
hospital catchment area, and service provision sector.
As a result, coordinating service efforts cross-town can
be complex.3 Carroll County is rural, with significant
distances between towns, and includes a large portion
of the White Mountain National Forest within its
borders as well as five state parks, dozens of lakes
and ponds, and several popular ski destinations. Few
public transportation options exist for those traveling
into and out of the region or between communities.
The local economy is heavily dependent on four-season
tourism which encompasses the hospitality, retail,
food, and beverage industries. The county has been
growing as a retirement and pre-retirement destination
for people throughout New England. This trend is
enhanced by technology that allows people to relocate
here and continue to work. “Compared to the state of
New Hampshire, it is considerably older, with 24.5% of
the population over the age of 65 compared to 15.9%
of New Hampshire residents. Carroll County compares
unfavorably to the State of New Hampshire on several
key socioeconomic measures including a significantly
lower median income and higher poverty rates. It also
has a higher proportion of single parent families.” 4
3 Carson, Jessica A. and Mattingly, Marybeth J.: “It’s a Whole Different World Up Here”: Carroll County Results from
the Carsey Study on Community and Opportunity, A Working Paper. Carsey School of Public Policy, UNH, 2015.
4 Memorial Hospital 2016 Community Health Needs Assessment: http://www.mainehealth.org/workfiles/mh_
community/CHNA%20County%20Report_Memorial_FINAL_6.23.16.pdf
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Carroll County Promise 2020
Data from the 2016 County Health Rankings show selected indicators related to health, access to
health and mental health care as well as the social determinants of health that play an important
role in determining optimal health outcomes.5
It is important to note that levels of poverty, disability, and education as well as the percentage
of children and people over 65 vary widely across town lines. Carsey School of Public Policy
researchers noted that “housing stock is another area in which the tourism and retirement
economy has impacted Carroll’s residents. In general, residents agree that housing costs—
particularly for renters—in Carroll County do not align with wage levels. Indeed, more than half of
Carroll’s renters (55.2%) spend 30 percent or more of their household income on rent and utilities,
19% meeting the definition of “cost burdened” set by the U.S. Department of Housing and Urban
Development.”6
5 2016 Carroll County Health Rankings: http://www.countyhealthrankings.org/app/new-hampshire/2016/rankings/
carroll/county/factors/overall/snapshot
6 Carson, Jessica A. and Mattingly, Marybeth J.: “It’s a Whole Different World Up Here”: Carroll County Results from
the Carsey Study on Community and Opportunity, A Working Paper. Carsey School of Public Policy, UNH, 2015.
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Carroll County Promise 2020
It is important to work with community partners addressing housing issues and other social
determinants of health. “Social determinants of health are the conditions in which people are
born, live, learn, work, play, worship and age that affect a wide range of health, functioning, and
quality-of-life outcomes and risks.” The effects of these social determinants of health “…should be
the concern of the entire healthcare community, not just public health practitioners.”7
7 Healthy People 2020: https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
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The Vision and Mission of Carroll County
Coalition for Public Health
Our Vision: All Carroll County residents will enjoy good health, a safe environment, and
opportunities to succeed and thrive at all phases of life through the proactive, coordinated and
comprehensive delivery of essential health services.
Our Mission: To realize this vision, Carroll County Coalition for Public Health will focus public
attention on 6 key public health priorities that impact residents across the lifespan, engage our
communities in evidence-informed solutions, and set clear benchmarks by which we will measure
our collective impact.
Carroll County Promise 2020
Community Health Improvement Plan Development
Planning Steps
In 2015 the PHAC reviewed key local population health data including the Huggins Hospital and
Memorial Hospital Community Needs Assessments (2013) and the Mt. Washington Valley Housing
Matters Report (2012). Data from the NH Citizens Health Initiative was reviewed to anticipate key
demographic trends likely to impact population health in Carroll County in the coming decades.
Local health factors and outcomes were compared with other counties in the state and nation
using data from the Annie E. Casey Foundation and the NH Social Vulnerability Index.
In 2016 the PHAC and PHAC Executive Committee continued to guide the work of the Public Health
Advisory Council Coordinator and the engagement of community partners by:
•Reviewing regional community health needs assessments and surveys
•Reviewing relevant regional data
•Providing information to community members
•Building and sustaining partnerships and coalitions
•Identifying emerging issues
•Ultimately prioritizing 6 regional public health initiatives
•Finalizing Carroll County Promise 2020 CHIP
Members of the C3PH Public Health Advisory Council attended the Community Forums of both
Memorial Hospital and Huggins Hospital to review the commonalities and overall themes in their
2016 Community Health Needs Assessments and through quarterly meetings worked to better
align the priorities in the Carroll County Promise 2020 CHIP.
11Carroll County Promise 2020
Setting Priorities for Carroll County 2020
As a result of the planning work noted above, six public health priorities were selected:
• Early Childhood and Early Parenting Support: Provide for the optimal development of
children and families living in Carroll County, ensuring all children enter kindergarten
healthy and ready to learn and thrive by 2020.
• Access to Comprehensive Behavioral Health Services: Improve access to a
comprehensive, coordinated continuum of behavioral healthcare services in Carroll County
by 2020.
• Substance Misuse and Addiction: Prevent and reduce substance misuse (including
alcohol, marijuana and prescription drugs) among all generations in Carroll County by
2020.
• Chronic Disease: Reduce the disease incidence and prevalence in Carroll County
in regards to chronic health conditions such as obesity, cancer, heart disease, diabetes,
hypertension and asthma.
• Aging with Connection and Purpose: Improve the health of older residents of our
communities by enhancing connection and purpose through collaboration with
community partners to address multiple social determinants of health including nutrition,
transportation, housing, home healthcare and community engagement.
• Public Health Emergency Preparedness Across the Life Span: Increase community
preparedness and individual preparedness of Carroll County residents and ensure that all
residents have access to mental health services if they seek sheltering services.
Objectives that are chosen in each priority area are readily measurable on an annual basis. To
address each objective, a small group of promising, evidence-informed strategic approaches
are identified that are already underway or can be embarked upon by county-wide workgroups to
make a difference. Workgroups will identify specific, attainable benchmarks which will be selected
to align with key objectives outlined in the New Hampshire State Improvement Plan as well as
objectives identified in the Memorial Hospital and Huggins Hospital Community Health Needs
Assessments. Benchmarks identified by the workgroups will be presented to the Public Health
Advisory Council Executive Committee for endorsement. Data indicators will be used to measure
our progress and hold ourselves accountable to the promise. C3PH, in partnership with other
organizations and individuals participating in our Public Health Advisory Council, is applying the
principles of a Collective Impact approach to solve these complex public health priorities. The
Carroll County Promise 2020 CHIP has been designed as a document with the ability to be flexible
to adapt to the changing needs of the region, with individual work plans to be created by the
workgroup addressing each priority. These work plans can be found at www.c3ph.org.
12Carroll County Promise 2020
Early Childhood and Early Parenting Support
Background
“New Hampshire is only as strong as our children, their families and the communities in
which they build their lives. We have a shared responsibility to one another to ensure
every child has the opportunity to succeed. It’s time to do more. Our future prosperity and
productivity as a state depends on investing in our children now.”
(NH Kids Count 2015 Data Book)
Established in 2015, the Carroll County Early Childhood Coalition (CCECC) identifies common
priorities and activities that will create a coordinated system of support for young children and
their families in Carroll County. The CCECC serves as a workgroup of Carroll County Coalition
for Public Health’s Community Health Improvement Plan addressing early childhood and early
parenting support with the mission to provide for the optimal development of children and families
living in Carroll County, ensuring all children enter kindergarten healthy and ready to learn and
thrive.
The Carroll County Early Childhood Coalition is also a member of Spark NH’s Early Childhood
Community of Practice in that it will strive to meet SparkNH’s stated goals:
• Children and families in NH have the best opportunities for early and life-
long health.
• Effective learning opportunities are provided in all settings including the
home, childcare and after school programs, preschools and elementary
schools from birth through the primary grades.
• Families have the skills, basic resources, and supports to promote their
children’s development and learning starting before birth and continuing
through the primary grades.
• NH’s young children and their families have the benefit of well-coordinated
early childhood programs and services that work effectively on their behalf. 8
8 SparkNH’s Framework for Action: http://sparknh.com/Framework-For-Action
13Carroll County Promise 2020
There were approximately 1782 children aged 0-4 in Carroll County in 2014. Carroll County had the
second highest number of children under 5 enrolled in the Women, Infant and Children Program in
2013, with 28.8% compared to a state average of 18.3%. “Growing up in poverty is one of the
greatest threats to healthy child development. Poverty and financial stress can impede children’s
cognitive development and their ability to learn. It can contribute to behavioral, social and
emotional problems and poor health.”9
Research has demonstrated that the likelihood of developmental delays and later health problems,
including heart disease, diabetes, substance abuse, and depression, increases for children who
have had a greater exposure to adverse childhood experiences. These experiences, also referred
to as “toxic stress,” may include physical or emotional abuse, chronic neglect, caregiver substance
abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic
hardship. Research also indicates that supportive, responsive relationships with caring adults as
early in life as possible can prevent or reverse the damaging effects of toxic stress response. 10
9 NH Kids Count: http://datacenter.kidscount.org/data/customreports/4431/any
10 Harvard University’s Center on the Developing Child: http://developingchild.harvard.edu/science/key-concepts/toxic-stress/
14Carroll County Promise 2020
Extensive research has also demonstrated that there are tremendous benefits for government and
society with investments made in early childhood education programs, not only to children and
their families, but to government and society as a whole. As documented in a Report to the White
House in December 2014 entitled “The Economics of Early Childhood Investments,” these benefits
include tax revenue increases and transfer payment decreases due to higher earnings, remedial
education and education system savings, reduced involvement with the criminal justice system as
well as overall improvements in health.11
State and Regional Assets
Carroll County is fortunate to have strong organizations engaged in early childhood education and
development that provide mutually-reinforcing activities and cooperative data sharing. State and
regional partners addressing this priority include:
• Tri-County Community Action Program/Head Start • Governor Wentworth Regional School District
• Children Unlimited • Granite State College
• Central NH Visiting Nurse Association • White Mountain Community College
• Women, Infant and Children Program • Moultonborough School District
• Memorial Hospital • SAU9
• Huggins Hospital • SAU13
• Saco River Medical Group • SPARK NH
• Childcare Aware of NH
• Mt. Washington Valley Children’s Museum
• Believe in Books Literacy Foundation
• White Mountain Community Health Center
• Carroll County Public Libraries
• Northern Human Services
11 White House Report: The Economics of Early Childhood Investments, December 2014: https://www.whitehouse.
gov/sites/default/files/docs/early_childhood_report1.pdf
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Goals, Objectives and Strategic Approach
16Carroll County Promise 2020
Summary
The Carroll County Early Childhood Coalition (CCECC) is a vibrant and active group of professionals
and stakeholders committed to improving supports for children and young families throughout
Carroll County. Working cooperatively and collaboratively, the CCECC will continue to identify
opportunities to engage new partners, share and leverage resources, and identify appropriate
evidence-informed initiatives to provide for the optimal development of children and families living
in Carroll County, ensuring all children enter kindergarten healthy and ready to learn and thrive.
Access to Comprehensive
Behavioral Health Services
Background
Although not specifically addressed in the NH State Health Improvement Plan as a state priority, “Injury
Prevention” and “Misuse of Alcohol and Other Drugs” are priorities that can be positively impacted
by increasing access to mental and behavioral health resources. Mental health is a state of successful
performance of mental function, resulting in productive activities, fulfilling relationships with other
people, and the ability to adapt to change and to cope with challenges. Mental health is essential to
personal well-being, family and interpersonal relationships, and the ability to contribute to community
or society. Stigma, additional health issues, access to services, and complexities of treatment delivery
also prevent many from receiving adequate treatment for their mental health issues. Access to mental
health providers was cited in both Huggins and Memorial Hospitals Community Needs Assessments
(CHNA) as a gap in the region. In Memorial Hospital’s CHNA 81% of stakeholders surveyed indicated
that depression plays a major role in the overall health of residents in the region, with 90% responding
that access to behavioral care/mental health care is a critical issue. The 2015 Youth Risk Behavior Survey
noted that 26.8% of high-school age youth felt sad or hopeless for at least 2 weeks straight, with 15% of
youth having seriously considered suicide. A shortage of behavioral health professionals can contribute
to reduced access and poorer health outcomes. 12
Carroll County is part of the catchment area of Northern Human Services, the designated mental health
center for the region. Northern Human Services also covers Coos and upper Grafton Counties, essentially
half of the geography of the state. In addition to mental health services provided by Northern Human
Services, the county has a number of private mental health and substance use disorder counselors,
primarily in the more heavily populated communities of Conway/North Conway and Wolfeboro.
In the 2016 County Health Rankings data was presented showing the ratio of the county population to
the number of mental health providers, which is comprised of psychiatrists, psychologists, licensed
clinical social workers, counselors, marriage and family therapists and advanced practice nurses
specializing in mental health care. In 2015, marriage and family therapists and mental health providers
that treat alcohol and other drug abuse were added to this measure.13 The graph below illustrates that
the ratio of population per mental health/behavioral health providers is higher than the state as a whole.
12 2015 Youth Risk Behavior Survey: https://wisdom.dhhs.nh.gov/ wisdom/#TopicGroup_8985E7A8FAD548A59514D91EAA707A9C
13 2016 Carroll County Health Rankings: http://www.countyhealthrankings.org/app/new-hampshire/2016/rankings/
carroll/county/factors/overall/snapshot
17Carroll County Promise 2020
While few in number, the mental/behavioral health providers in the community offer a variety
of services and specialty areas. There are, however, few providers, aside from Northern Human
Services, who provide services to uninsured or underinsured persons. Additionally, there is a
dramatic lack of psychiatrists both in New Hampshire and across the country. Recent headlines
highlighting substance misuse and addiction in Carroll County have raised the level of community
awareness regarding substance use disorders significantly. A workgroup to address access and
continuum of care for behavioral health services is being identified and will closely align with
the objectives and strategies under the 1115 Medicaid Transformation Waiver Program as part of
the efforts of Integrated Delivery Network #7 to transform NH’s behavioral health delivery system
and better integrate behavioral health with primary care. “Mental health and physical health are
closely connected. Mental health plays a major role in people’s ability to maintain good physical
health. Mental illnesses, such as depression and anxiety, affect people’s ability to participate in
health-promoting behaviors. In turn, problems with physical health, such as chronic diseases, can
have a serious impact on mental health and decrease a person’s ability to participate in treatment
and recovery.”14 In terms of substance use, NH is above the US average for alcohol and illegal
drug use,15 with the 2nd highest rate in the US for alcohol use and the 10th highest rates for illegal
drug use. Additional assessments that will help inform this work in the future include the 2016
Gaps and Assets Assessment Report completed by C3PH’s Continuum of Care Facilitator. Although
physical health, mental health and substance use disorders are linked, each specialty requires
different training and expertise and there are few truly integrated treatment options.
Mental Health Indicators – Individuals Age 18 and Up
Mental Health Issue New Hampshire United States
Serious Mental Illness-Past Year 4.73% 4.15%
Major Depressive Episode – Past Year 7.90% 6.63%
Had Thoughts of Suicide – Past Year 4.12% 3.94%
Source: National Survey on Drug Use and Health, 2013-2014
14 Healthy People 2020: https://www.healthypeople.gov/2020/topics-objectives/topic/mental-health-and-mental-
disorders
15 National Survey on Drug Use and Health, 2013-2014: http://www.samhsa.gov/data/population-data-nsduh
18Carroll County Promise 2020
State and Regional Assets
Many organizations across the county are realizing that it is crucial to work together to address
the challenges of improving the access to comprehensive behavioral health services. State and
regional partners currently addressing this priority include:
• Tri-County Community Action Program
• Memorial Hospital
• Huggins Hospital
• Saco River Medical Group
• White Mountain Community Health Center
• Ossipee Family Planning and Teen Clinic
• T. Murray Wellness Center
• Tamworth Community Nurse Association
• Visiting Nurse Homecare and Hospice
• Central NH Visiting Nurse Association
• Service Link of Carroll County
• Northern Human Services
• Sinfonia Family Services of New Hampshire
• Governor Wentworth Regional School District
• Moultonborough School District
• SAU9
• SAU13
• Children Unlimited: Carroll County Family Resource Center
19Carroll County Promise 2020
Goals, Objectives and Strategic Approach
20Carroll County Promise 2020
Summary
During the spring and summer of 2015, C3PH coordinated multiple suicide prevention-related
activities focused on steps that all of us can take to better recognize individuals who may be
experiencing mental health challenges in our communities. Efforts involved leaders from local
schools, law enforcement, and print and media outlets who participated in training about safe
messaging about suicide, as well as CALM (Counseling on Access to Lethal Means) and suicide
prevention trainings with several local schools and community group.
Moving forward, eight local volunteers from towns and school districts across the county have
been certified as trainers in the NAMI-NH’s nationally recognized CONNECT Suicide Prevention
and Postvention curricula. Another local volunteer has been approved as a trainer for the national
best practice CALM initiative. These local volunteers stand ready to provide no-cost training to
schools and community groups to better connect people in crisis to care. Local innovations such
as the long-standing Moultonborough Mental Health and Suicide Coalition has been successful in
securing local access to mental health services for town residents. This type of model is one that
Northern Human Services and multiple local partners including schools, faith groups, and law
enforcement are eager to adapt to other towns or town coalitions. In 2016 the SAU9 Health and
Wellness Committee identified that Social and Emotional Health will be a priority to address in
their updated Health and Wellness Plan.
Our county residents and community partner organizations will continue to collaborate in
the future to ensure all Carroll County residents have access to high quality, coordinated and
comprehensive behavioral health services.
21Carroll County Promise 2020
Substance Misuse and Addiction
Background
New Hampshire has experienced increased heroin use in the past year. Overdose deaths in 2015
were 439, with 22 deaths occurring in Carroll County. From 2013 to 2015 there was a 128.6%
increase in the number of all drug deaths. The Office of the Chief Medical Examiner predicts that
there will be approximately 488 drug related deaths in 2016.16
All drug overdose deaths involving opioids
Age-adjusted rate; All Sexes; All ages; 2010-2014
County with Manchester and Nashua
Source: www.wisdom.dhhs.nh.gov, 2016
Alcohol abuse remains a problem for New Hampshire families as well. 29.9% of our high-school
age children currently drink alcohol, with 42.3% of students usually obtaining the alcohol from
someone giving it to them.17 Carroll County data suggests that substance misuse among our
high school population ranks among the highest in the state; qualitative data suggests that our
young adult population is heavily involved in binge drinking, opiate use and engaged in negative
behaviors to support their opiate use. Often children are present when law enforcement takes
action, and the impact on families is devastating.
16 Office of the Chief Medical Examiner: https://wisdom.dhhs.nh.gov/c10/epht/Document/ME20161007.pdf
17 NH DHHS Youth Risk Behavior Survey http://www.dhhs.nh.gov/dphs/hsdm/yrbs.htm
22Carroll County Promise 2020
Carroll County has an active Prevention Leadership Team that has been planning and working to
address substance use disorder issues in the county. In 2015 representatives from all segments
of the community engaged in planning for and executing a county-wide community event: From
Silence to Solutions: Carroll County Tackles Heroin. Since then individuals who participated in that
event have met in work groups to develop specific activities designed to reduce stigma associated
with substance use disorders, to promote evidence-based program implementation among health-
care providers, and to support increased substance use disorder treatment and recovery support
services across the county.
The Prevention Leadership Team is the work group addressing substance misuse in the Carroll
County Public Health Network. They guided the development of the Carroll County Regional
Substance Misuse Prevention Strategic Plan 2016-2019 (available at www.c3ph.org.) and meet
bimonthly to receive updates on the progress of the annual prevention work plan. Members of
this group as well as the Continuum of Care Facilitator in the region are able to provide expertise
and assistance to other Public Health Council Advisory Work Groups including the Early Childhood
and Aging work groups to ensure that partners have the tools necessary to enhance prevention,
intervention, treatment and recovery supports for their special populations.
State and Regional Assets
The following is a sampling of the organizations actively involved in substance use disorder
prevention, intervention, treatment and recovery support efforts in Carroll County:
• Conway Daily Sun
• Tri-County Community Action Program
• Salmon Press (Granite State News and Carroll
• Memorial Hospital
County Independent)
• Huggins Hospital
• Mt Washington Valley Chamber of Commerce
• White Mountain Restorative Justice Program
• Ad Hoc Providers Group
• White Mountain Community Health Center
• Kingswood Youth Center
• Northern Human Services
• Appalachian Mountain Teen Project
• Sinfonia Family Services of New Hampshire
• WMWV and WASR Radio Stations
• Governor Wentworth Regional School District
• Moultonborough School District
• SAU9
• Paul School, Wakefield
• Ossipee Congregational Church
• NH State Police
• Carroll County Sheriff’s Department
• Tuftonboro Police Department
• Wakefield Police Department
• Wolfeboro Police Department
• Sandwich Police Department
• Ossipee Police Department
• Tamworth Police Department
• Conway Police Department
• Bartlett Police Department
• Moultonborough Police Department
• Carroll County Police Chiefs
23Carroll County Promise 2020
Goals, Objectives and Strategic Approach
24Carroll County Promise 2020 25
Carroll County Promise 2020
Summary
The workgroup addressing the priority of Substance Misuse and Addiction in Carroll County
builds on the work of the Substance Misuse Prevention Network and the Continuum of Care
Facilitator. It continues to advocate for increased access to substance use disorder services in the
county and to build the capacity of our public health network partners to provide evidence-based
prevention, intervention, treatment and recovery support services through training and technical
assistance, such as those available through Anyone/Anytime and Partnership for a Drug Free
NH. By increasing the awareness of the substance misuse problem throughout our communities,
the workgroup hopes to destigmatize mental health and substance use disorder treatment and
recovery support.
26Carroll County Promise 2020
Chronic Disease
Background
Eating a healthy diet, being physically active and maintaining a healthy weight are essential for an
individual’s overall health and the treatment and prevention of existing chronic health conditions
from worsening over time. According to the National Center for Chronic Disease Prevention
and Health Promotion, it is estimated that treatment for chronic diseases account for 86% of
our nation’s health care costs.18 “25.8% of adults in Carroll County have three or more chronic
health conditions, with respiratory diseases, cancer, cardiovascular diseases and diabetes being
the most prevalent.”19 Many of these chronic diseases can be attributed to obesity, which is
defined by the Centers for Disease Control and Prevention as “weight that is higher than what is
considered as a healthy weight for a given height as determined by a person’s Body Mass Index
(BMI).20 A person with a BMI of 25-30 falls within the overweight range, while a person with BMI
higher than 30 is considered obese. “Obesity is a complex health issue that is a result of genes,
metabolism, behavior, environment, culture and socio-economic status.”21
Obesity among adults
Percent of adults who are obese; Both Genders
County with Manchester and Nashua; 2015
Source: www.wisdom.dhhs.nh.gov,2016
18 Centers for Disease Control and Prevention: http://www.cdc.gov/chronicdisease/
19 Memorial Hospital Community Health Needs Assessment, 2016: http://www.mainehealth.org/workfiles/mh_
community/CHNA%20County%20Report_Memorial_FINAL_6.23.16.pdf
20 Centers for Disease Control and Prevention: https://www.cdc.gov/obesity/adult/defining.html
21 NH Health WISDOM: https://wisdom.dhhs.nh.gov/wisdom/#Topic_C592D4F396C546058649E106C802DB89_
Anon
27Carroll County Promise 2020
73% of community stakeholders interviewed as part of the 2016 Memorial Hospital CHNA stated
childhood obesity was the most important issue in family health, with 81% saying obesity was the
biggest chronic disease issue. Huggins Hospital discovered in their community survey of over 300
families in their region that 80% of the respondents had one of more of the following diseases:
• High blood pressure/hypertension (46%)
• High cholesterol (34%)
• Arthritis (32%)
• Overweight or obese (24%)
• Cancer (19%)
• Diabetes (17%)
• Heart disease (12%)
• Asthma (11%) 22
Programs in Carroll County are already underway to address obesity as well as access to specialty
care and coordination of care for residents who suffer from multiple chronic diseases. Examples of
the programs include Diabetes and Prediabetes Education Classes, “Let’s Go” Childhood Obesity
Prevention Program,23 “Better Choices, Better Health”,24 Aqua Therapy and Water Aerobics25 and
“Slow Cooker” classes.26
State and Regional Assets
Carroll County is fortunate to have organizations who are already partnering across sectors to
collaborate and offer programs to help people to lead healthy and active lifestyles. State and
regional partners to date include:
• Huggins Hospital
• Memorial Hospital
• White Mountain Community Health Center
• Saco River Medical Group
• Northern Human Services
• Tri-County Community Action Program/Head Start
• University of New Hampshire Cooperative Extension
• Children Unlimited
• Believe in Books Literacy Foundation
• Bartlett Community Preschool
• Governor Wentworth Regional School District
• Moultonborough School District
• SAU9
• SAU13
• Mt. Washington Valley Trails Association
•Carroll County Recreation Departments
22 Huggins Hospital Community Health Needs Assessment, 2016:
23 http://www.letsgo.org/
24 http://www.memorialhospitalnh.org/health-wellness/better-choices-better-health
25 https://www.hugginshospital.org/services/aquatic-therapy
26 https://extension.unh.edu/Food-Health
28Carroll County Promise 2020
Goals, Objectives and Strategic Approach
29Carroll County Promise 2020
Summary
The Carroll County Public Health Network is committed to reducing the rates of chronic diseases
among our Carroll County residents by facilitating and convening organizations to expand
community education and programming accessible to all Carroll County residents aimed at
promoting healthy and active lifestyles and good nutrition and eating habits. By working together
in community partnerships including schools, healthcare providers, businesses and governmental
entities we will work to bring about the transformational change needed in our culture to reduce
obesity rates in order to improve long-term health outcomes and reduce healthcare costs.
30Carroll County Promise 2020
Aging with Connection and Purpose
Background
According to projections by the NH Citizen’s Health Initiative, Carroll County is older and aging faster
than any other county in the State of NH. Indeed, the population age ratio (ratio of people under 25
and over 65 to the working age population) is expected to hit nearly 120% by 2030, and all of the
age-ratio gain will be in the over 65 age range as child population is projected to decrease. Ratios of
80% or higher are widely considered unsustainable, as fewer and fewer working residents are called
on to provide services for an expanding older population.27
Carroll County Population Pyramid, 201428
As the human and financial resources available to support elderly residents shrinks, it will be
essential to find ways to address issues of nutrition, transportation, housing, home healthcare
and overall community engagement for our seniors in order to reduce hospital admissions so as to
control health care costs and increase quality of life for our elders. This is very important to consider
as Carroll County is projected to have the highest primary care demand of any county in the state by
2030 according to the NH Citizens Health Initiative.29
Steps must be taken to help residents prepare for aging by planning ahead for their physical, social,
emotional, and financial health. Programs that help prevent falls and their effects on the overall
health and housing consequences must be a top priority for Carroll County going forward.
27 MapNH Health, a project of the NH Citizen’s Health Initiative, a program of UNH’s Institute for Health Policy and
Practice: http://www.mapnhhealth.org/health-map?map=county®ion=null&ind=2643&year=2020
28 Source: U.S. Census Bureau, Population Estimates, 2014
29 MapNH Health, a project of the NH Citizen’s Health Initiative, a program of UNH’s Institute for Health Policy and
Practice: http://www.mapnhhealth.org/health-map?map=county®ion=null&ind=2644&year=2020
31Carroll County Promise 2020
According to data compiled by NH Health WISDOM:30
• Deaths due to falls in older adults have increased between 2000 and 2013.
• More males age 65 and older are seen in the emergency department due to falls
than females.
• More females age 65 and older need inpatient hospital care due to falls than males.
• The higher a person’s age is, the more likely they are to need hospital care or die from
a fall.
As stated in NH’s State Health Improvement Plan(2013-2020), “in 2009 in New Hampshire, the total
approximate cost of emergency and inpatient hospital visits due to falls in the older adult was 105.6
million dollars.”31 Carroll County seniors are fortunate to have a variety of falls prevention programs
through local hospitals, nursing homes and senior centers. Additional innovative approaches to
reduce hospital admissions in the population over 65 years in age include town-wide “Good Morning
Programs” and other neighbor care programs. The Tamworth Community Nurses Association(TCNA)
provides preventive well-checks for residents of all ages, a service that is particularly helpful for
older residents and their families who are attempting to balance the goal of independent living with
housing, social, and physical needs. Through close collaboration and sharing of resources local
communities can learn and adapt programs that will best serve their town’s aging populations.
An example of this connectivity is the support and promotion of the New Life Program at Memorial
Hospital that supports mothers suffering from addiction.
State and Regional Assets
The following is a list of the organizations actively involved with issues affecting our aging
populations in Carroll County:
• Tri-County Community Action Program
• Memorial Hospital/Merriman House
• Huggins Hospital
• White Mountain Community Health Center
• Tamworth Community Nurse Association
• Visiting Nurse Homecare and Hospice
• Central NH Visiting Nurse Association
• Service Link of Carroll County
• Northern Human Services
• Wolfeboro Senior Center
• Gibson Senior Services
• Abundant Blessings
• Mineral Springs/Genesis Healthcare
• Timberland Homecare
• Mountainview Nursing Home
• Cooper, Cargill, Chant Attorneys at Law
• Law Offices of G. Thomas Bickford
• MWV Housing Coalition
30 NH Health WISDOM: Older Adult Falls Community Profile: https://wisdom.dhhs.nh.gov/
wisdom/#CommunityProf_61C0C7A4A23F4C1792E8EB9804D25154_Anon
31 NH State Health Improvement Plan (2013-2020) from 2005-2009 Elder Falls Issue Brief: http://www.dhhs.nh.gov/
dphs/documents/nhship2013-2020.pdf
32Carroll County Promise 2020
Goals, Objectives and Strategic Approach
33Carroll County Promise 2020
Summary
Carroll County’s aging population, many of whom reside in Carroll County without extended family
supports, is projected to continue to increase in the years ahead. A workgroup has already formed
to address the objectives and strategic approaches as stated in the CHIP. Members of this workgroup
are addressing additional concerns including transportation, housing, and home care challenges
through increased cooperation, collaboration and leveraging of resources among other community
partners.
In the short term, there are already initiatives and programs in place to enhance balance (Matter of
Balance), provide quality, nutritional meals (Meals on Wheels, congregate meals), conduct home
safety assessments and a variety of social programming to ensure our aging population feels a
sense of connection and purpose within the broader Carroll County communities. Looking to the
future, our community partners will continue to explore and consider evidence-based programs such
as adult day programs and innovative housing options so as to enable our residents to age with
connection and purpose as valued members of our communities.
34Carroll County Promise 2020
Public Health Emergency Preparedness
Across the Lifespan
Background
Public Health Emergency Preparedness is an important aspect of community health. The Carroll
County Coalition for Public Health receives guidance from the Centers for Disease Control and
Prevention (CDC) on the preparedness capabilities that are necessary in the event of a public health
threat. Threats can include the spread of infectious disease, environmental events, bio-chemical
hazards, acts of terrorism or natural disasters.
Carroll County Coalition for Public Health recognizes that in order to protect and preserve the health
of the people of this region, it is of utmost importance to be prepared for any health hazard that
could arise. A robust plan for Public Health Emergency Preparedness and Response region-wide has
been developed, but a plan in writing needs to translate to real action to protect the population’s
health. In 2015 a public health hazard vulnerability assessment was conducted, through focus
groups and workshop sessions with public health and wellness oriented leaders in the Carroll
County community. Out of this series of meetings, an Action Plan was created which prioritized how
the region can best focus on Emergency Preparedness improvements over the months and years to
come. Partners pointed out the importance of integration of behavioral health resources as a key to
preparedness, and also focused on how to help our children learn how to be safe, well and prepared,
and share this knowledge with their families.
In 2015 and 2016 the Citizens Corps Council was strengthened in Carroll County, and for the
first time, volunteers completed 20-hour Community Emergency Response Team (CERT) training
in addition to Medical Reserve Corps (MRC) orientation. 21 new volunteers were added to the
organization by June 2016. The growing cadre of regional volunteers have participated in several
response activities across the region. Some of these have included: a search and rescue with NH
Fish and Game, assisting with the school based vaccination program in 13 schools, working at
County Naloxone Distribution events, and staffing Points of Dispensing centers. The School Based
Clinics program vaccinated over 800 children in 2015 from the flu at no cost to families, resulting in
reduced absenteeism and illness in our County. The program will continue in the next three years,
with partnership of the Visiting Nurses Association.
In 2016 two major Emergency Preparedness exercises were conducted around the concept of
Point of Dispensing (POD), focusing on the Conway Middle School POD site serving the northern
portion of the region. A Point of Dispensing (POD) is a place where vaccines, antibiotics, and other
medications or supplies can be quickly dispensed to a large number of people during a widespread
outbreak of disease. A POD may also be used to respond to a range of public health events or
emergencies. The first exercise, in April 2016, focused on establishing a quick and effective set up
for the POD site. The second exercise was conducted in August 2016 over two days, and was a part
of a large State-Wide full scale effort to practice distribution of medicine from the Centers for Disease
Control’s Strategic National Stockpile.
In addition to dispensing vaccine or medication quickly and accurately to the public, a POD is
designed to serve all clients, including those with functional needs (language and literacy barriers,
physical and cognitive disabilities, elders and children). The integration of these functional needs
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